1. Field
This invention relates generally to the field of medicine and more specifically to a system and method for targeting rhythm irregularities and other rhythm disorders of biological rhythms using shaped ablation. In particular, the present invention can be applied to minimally invasive techniques or surgical techniques to detect, diagnose and treat the biological rhythm disorders. Some embodiments are directed to disorders of heart rhythm, others to electrical disorders of the brain and nervous system and still others to electrical or contractile disorders of the smooth muscle of the gastrointestinal and genitourinary systems.
2. Brief Description of the Related Art
Heart rhythm disorders are very common in the United States, and are significant causes of morbidity, lost days from work, and death. Heart rhythm disorders exist in many forms, of which the most complex and difficult to treat are atrial fibrillation (AF), ventricular tachycardia (VT) and ventricular fibrillation (VF). Other rhythms are more simple to treat, but may also be clinically significant including atrial tachycardia (AT), supraventricular tachycardia (SVT), atrial flutter (AFL), premature atrial complexes/beats (SVE) and premature ventricular complexes/beats (PVC). Under certain conditions, rapid activation of the normal sinus node can cause the heart rhythm disorder of inappropriate sinus tachycardia or sinus node reentry.
Treatment of heart rhythm disorders, particularly the complex rhythm disorders of AF, VF and VT, can be very difficult. Pharmacologic therapy is particularly suboptimal for AF (Singh, Singh et al. 2005) and VT or VF (Bardy, Lee et al. 2005) and, as a result, there is considerable interest in non-pharmacologic therapy. Ablation is a promising and increasingly used therapy to eliminate heart rhythm disorders by maneuvering a sensor/probe to the heart through the blood vessels, or directly at surgery, then delivering energy to the cause(s) for the heart rhythm disorder to terminate it. Ablation was initially used for ‘simple’ disorders such as SVT, AFL, PVC, PAC, but is increasingly used for treatment of AF (Cappato, Calkins et al. 2005), VT (Reddy, Reynolds et al. 2007) and, to a lesser extent, VF (Knecht, Sacher et al. 2009).
Ablation therapy has been increasingly applied to treat simple and complex heart rhythm disorders. However, the manner in which ablation is applied was derived and adapted from simple heart rhythm disorders, in which activation does not vary from beat to beat, without a clear appreciation of the critical differences in treating complex heart rhythm disorders, in which activation varies from beat to beat.
In particular, almost all ablation therapy is delivered to heart tissue as a single point ablation (or ‘lesion’) or as a combination of such lesions with the object of bisecting a continuous reentry circuit to join non-conducting regions of the heart (often by contiguous clusters of such ‘point regions’). This is based on the concept that simple rhythms, such as atrial tachycardias, pulmonary vein tachycardias, focal ventricular tachycardias, atrioventricular nodal reentry and atrioventricular reentry requiring an accessory pathway involve specific abnormalities at small point regions of the heart. After identifying the locations, ablation is applied to these point regions. Other simple rhythms, exemplified by typical and atypical atrial flutter, involve passage of electrical activation through a special region of tissue called an “isthmus”. Ablation is then achieved by a contiguous series of points often named an ablation “line” designed to interrupt or bisect the isthmus, although such ablation lines are often not linear if examined surgically (Cox, Heart Rhythm 2005).
However, ablation therapy for complex rhythm disorders in which activation paths may change from beat-to-beat, such as atrial fibrillation, polymorphic ventricular tachycardia or ventricular fibrillation, is far more difficult. This is in part because tools to identify and locate the cause of the heart rhythm disorder are poor, hindering attempts to deliver energy to the correct region to terminate and eliminate the disorder. In persistent AF, a highly prevalent form of AF, ablation has a one procedure success rate of only 50-60% (Cheema, Vasamreddy et al. 2006; Calkins, Brugada et al. 2007) despite lengthy 4-5 hour procedures and a 5-10% rate of serious complications (Ellis, Culler et al. 2009) including death (Cappato, Calkins et al. 2009).
For ‘simple’ disorders such as atrial tachycardia, tools do not exist to precisely identify the size and shape of ablation therapy. This is particularly important since electrical activation does not spread concentrically within the heart from a point source. Differences in longitudinal versus transverse conduction from normal structures such as the sinus node are well described even in normal tissue (Fedorov, 2009 #5273; Fedorov, 2010 #5738), and may be more dramatic in abnormal tissue that sustains atrial tachycardias (Higa, 2004 #1686). Nevertheless, the approach to ablation of these rhythms involves either a clustering of points or an ablation ‘line’.
Even less is known about the size and shape of ablation therapy to eliminate complex rhythms such as atrial fibrillation (AF), polymorphic ventricular tachycardia or ongoing ventricular fibrillation. Ablation of AF provides a stark example where ablation in many patients typically destroys more than 50% of the atrial surface (Cox, Heart Rhythm 2005), yet has a single procedure cure rate at one year of 50-60% (Calkins, Heart Rhythm 2012; Weerasooriya, J Am Coll Cardiol. 2011). This discrepancy is due to the fact that the sources for AF are extremely difficult to identify. Accordingly, the precise size and shape of ablation to treat AF is essentially unknown. The ablation of substantial portions of heart tissue without clear evidence of their involvement in the rhythm disorder may explain the 5-10% risk of adverse effects from AF ablation (Dixit, Heart Rhythm 2007; Ellis, Heart Rhythm 2009), including death from perforation of the heart into the esophagus, narrowing (stenosis) of the pulmonary veins, damage to the phrenic nerve, and the recently described stiff left atrial syndrome in extreme atrial destruction from ablation leads to a non-distensible chamber, which leads to heart failure even in previously healthy AF patients (Gibson, Heart Rhythm 2011).
The vast majority of catheter systems used for ablation therapy deliver lesions as points from a tip at the end of a tubular/shaft catheter. Ablation lines are achieved by moving the catheter tip to contiguous locations, but this is empiric with regards to the rhythm disorder source. Although newer systems have been designed to ablate different shapes, such as the PVAC, TVAC or MAC catheters by Ablation Frontiers (Scharf, 2009), these shapes are also empiric (the line shape of the TVAC, or the star shape of the MAC) or designed to conform to anatomic regions (such as the pulmonary vein ostium for the PVAC). None of the catheter systems is designed to conform ablation therapy to the shape of the actual source of the rhythm disorder within heart tissue, since such source shapes are currently not discussed, studied or defined, particularly for complex heart rhythm disorders.
Difficulties in identifying the precise source of a heart rhythm disorder for ablation depend on the fact that most sophisticated known systems display data that the practitioner has to interpret, without directly identifying and locating the cause of the disorder to enable the practitioner to detect, diagnose and treat it. This includes currently used methods, described in U.S. Pat. No. 5,662,108, U.S. Pat. No. 5,662,108, U.S. Pat. No. 6,978,168, U.S. Pat. No. 7,289,843 and others by Beatty and coworkers, U.S. Pat. No. 7,263,397 by Hauck and Schultz, U.S. Pat. No. 7,043,292 by Tarjan and coworkers, U.S. Pat. No. 6,892,091 and other patents by Ben-Haim and coworkers and U.S. Pat. No. 6,920,350 by Xue and coworkers. These methods and instruments detect, analyze and display electrical potentials, often in sophisticated 3-dimensional anatomic representations, but still fail to identify and locate the cause of heart rhythm disorders, particularly for complex disorders such as AF. This is also true for patents by Rudy and coworkers (U.S. Pat. Nos. 6,975,900 and 7,016,719, among others) that use signals from the body surface to ‘project’ potentials on the heart.
Certain known methods for identifying and locating causes for heart rhythm disorders may work in simple rhythm disorders, but there are no known methods that have been successful with respect to identifying causes for complex disorders such as AF, VF or polymorphic VT. Moreover, no technique currently identifies the size and shape of ablation therapy to eliminate the heart rhythm disorder while minimizing damage to non-involved (normal) tissue of the heart. Activation mapping (tracing activation back to the earliest site) is useful only for simple heart rhythm disorders such as tachycardias, works poorly for AFL (a continuous rhythm without a clear ‘start’), and not at all for AF with variable activation paths. Entrainment mapping uses pacing to identify sites where the stimulating electrode is at the cause of a rhythm, yet pacing cannot be applied in AF and even some ‘simple’ rhythms such as atrial tachycardias due to automatic mechanisms. Stereotypical locations are known for the cause(s) of atrioventricular node reentry, typical AFL and patients with early (paroxysmal) AF, but not for the vast majority of patients with persistent AF (Calkins, Brugada et al. 2007), VF and other complex disorders. Thus, no methods yet exist to precisely identify the position, size and shape of sources for complex heart rhythm disorders such as AF (Calkins, Brugada et al. 2007) for ablation while minimizing damage to surrounding tissue that is not involved in the rhythm disorders.
An example of a system for ‘simple’ rhythms with consistent activation from beat to beat is given by U.S. Pat. No. 5,172,699 by Svenson and King. This system is based upon finding diastolic intervals that can be defined in ‘simple rhythms’, but not in complex rhythms such as atrial fibrillation (AF) or ventricular fibrillation (VF) (Calkins, Brugada et al. 2007; Waldo and Feld 2008). Moreover, this system does not identify or locate a cause, since it examines diastolic intervals (between activations) rather than activation itself. In addition, it is focused on ventricular tachycardia rather than AF or VF, since it analyzes periods of time between QRS complexes on the ECG.
Another example is U.S. Pat. No. 6,236,883 by Ciaccio and Wit. This system uses a concentric array of electrodes to identify and localize reentrant circuits. Accordingly, this will not find non-reentrant causes such as focal beats. Moreover, the method of using feature and detection localization algorithms will not work for complex rhythms such as AF and VF, where activation within the heart changes from beat to beat. It identifies ‘slow conduction within an isthmus of the reentry circuit’, which is a feature of ‘simple’ arrhythmias such as ventricular tachycardia, but is not defined for AF and VF. Moreover, the size and shape of the isthmus are not defined, such that ablation is directed empirically to a point, an amorphous cluster of points (with an unclear endpoint of when to stop ablating) or a ‘line’.
In U.S. Pat. No. 6,847,839, Ciaccio and coworkers describe an invention to identify and localize a reentry circuit in normal (sinus) rhythm. Again, this will not find causes for an arrhythmia that are not reentrant but focal, from where activation emanates radially. Second, this patent is based on the presence in sinus rhythm of an “isthmus” for reentry, which is accepted for ‘simple’ rhythms with consistent activation between beats such as VT (see (Reddy, Reynolds et al. 2007)). However, this is not accepted for complex rhythms with varying activation paths such as AF or VF.
U.S. Pat. No. 6,522,905 by Desai uses the principle of finding the earliest site of activation, and determining this to be the cause of an arrhythmia. This approach will not work for simple arrhythmias due to reentry, in which there is no “earliest” site in reentry because activation is a continuous ‘circle’. This approach will also not work for complex arrhythmias in which activation varies from beat to beat, such as AF or VF.
However, even in simple heart rhythm disorders, it is often difficult to apply known methods to identify causes. For instance, ablation therapy success for atrial tachycardias (a ‘simple’ disorder) may be as low as 70%. When surgeons perform heart rhythm disorder procedures (Cox 2004; Abreu Filho, 2005) it is ideal for them to be assisted by an expert in heart rhythm disorders (cardiac electrophysiologist). Thus, ablating the cause of a heart rhythm disorder can be challenging, and even experienced practitioners may require hours to ablate certain ‘simple’ rhythm disorders (with consistent beat-to-beat activation patterns) such as atrial tachycardia or atypical (left atrial) AFL. The situation is more difficult still for complex heart rhythm disorders such as AF and VF where activation sequences vary from beat-to-beat.
Diagnosing and treating heart rhythm disorders often involves the introduction of a catheter having sensors (or probes) into the heart through the blood vessels. These sensors detect electrical activity at the sensor locations in the heart. The prior art for diagnosing rhythm disorders often measures times of activation at the sensors. However, such prior art has been applied to signals that, at each recording site (or sensor location), are quite consistent from beat to beat in shape and often timing. These prior art solutions are extremely difficult to apply to complex rhythms such as AF or VF where signals for each beat at any site (‘cycle’) may transition between one, several, and multiple deflections over a short period of time. When a signal, for instance in AF, comprises 5, 7, 11 or more deflections, it is difficult if not impossible to identify which deflections in the signal are at or near the sensor (‘local’) versus a further removed site in the heart sensed by the sensor (‘far-field’), as noted in studies to analyze AF rate (Ng and coworkers, Heart Rhythm 2006). In another recent report, signals in rhythms, such as AF, require ‘interactive methods’ to identify local from far-field activations (Elvan et al. Circulation: Arrhythmias and Electrophysiology 2010).
In the absence of methods to identify and locate causes for human AF, physicians have often turned to the animal literature. In animal models, localized causes for complex and irregular AF (induced by artificial means) have been identified and located in the form of localized ‘electrical rotors’ or repetitive focal beats (Skanes, Mandapati et al. 1998; Warren, Guha et al. 2003). In animals, rotors are indicated by signals that show a high spectral dominant frequency (DF) (a fast rate) and a narrow DF (indicating regularity) (Kalifa, Tanaka et al. 2006). Such uses of spectral dominant frequencies is described in U.S. Pat. No. 7,117,030 issued to Berenfeld and coworkers.
Unfortunately, these animal data have not translated into effective human therapy. Animal models of AF and VF likely differ from human disease. For instance, animal AF is rarely spontaneous, and it rarely initiates from pulmonary vein triggers (that are common in human paroxysmal AF). Both AF and VF are typically studied in young animals without the multiple co-existing pathology (Wijffels, Kirchhof et al. 1995; Gaspo, Bosch et al. 1997; Allessie, Ausma et al. 2002) seen in older humans who typically experience these conditions.
In AF patients, sites where rate is high (or, sites of high spectral dominant frequency, DF) have not been useful targets for ablation. A recent study by Sanders and coworkers showed that AF rarely terminated with ablation at sites of high DF (Sanders, Berenfeld et al. 2005a). Other studies show that sites of high DF are common in the atrium, and ablation therapy at these sites does not acutely terminate AF (as would be expected if high DF sites were causes) (Calkins, Brugada et al. 2007). In part, this may be because the DF method that is effective in animals may be inaccurate in human AF for many reasons, as shown by many workers (Ng, Kadish et al. 2006; Narayan, Krummen et al. 2006d; Ng, Kadish et al. 2007). Nademanee and coworkers have suggested that signals of low amplitude with high-frequency components (complex fractionated atrial electrograms, CFAE) may indicate AF causes (Nademanee, McKenzie et al. 2004a). This diagnostic method has been incorporated into commercial systems by Johnson and Johnson and Biosense. However, this method has also been questioned. Oral and coworkers showed that ablation of CFAE does not terminate AF or prevent AF recurrence alone (Oral, Chugh et al. 2007) or when added to existing ablation (Oral, Chugh et al. 2009).
Several inventions in the prior art acknowledge what was felt true until now—that AF is a “cardiac arrhythmia with no detectable anatomical targets, i.e., no fixed aberrant pathways,” such as U.S. Pat. No. 5,718,241 by Ben-Haim and Zachman. This patent, as a result, does not identify and locate the cause for a heart rhythm disorder. Instead, it focuses treatment on heart geometry by delivering lines of ablation to “interrupt each possible geometric shape.” This patent creates maps of various parameters and geometries of the heart, rather than of the actual causes of the heart rhythm disorder.
Many inventions use surrogates for the actual cause for a cardiac arrhythmia, without identifying and locating the cause. For instance, U.S. Pat. No. 5,868,680 by Steiner and Lesh uses measures of organization within the heart, which are constructed by comparing the activation sequence for one activation event (beat) to the activation sequence for subsequent beats, to determine if “any spatiotemporal order change has occurred”. However, that invention assumes that organization is greatest near a critical site for AF and is lower at other sites. However, this assumption may not be correct. In animal studies, indexes of organization fall with distance from an AF source, then actually increase again as activation re-organizes at more distant sites (Kalifa, Tanaka et al. 2006). Moreover, U.S. Pat. No. 5,868,680 requires more than one beat. As a result, methods such as in U.S. Pat. No. 5,868,680 identify many sites, most of which most are not causes of AF. This lack of identifying and locating a cause for AF may explain why methods based on organization have not yet translated into improved treatment to acutely terminate AF.
Similarly, U.S. Pat. No. 6,301,496 by Reisfeld is based on the surrogate of mapping physiologic properties created from a local activation time and vector function. This is used to map conduction velocity, or another gradient function of a physiologic property, on a physical image of the heart. However, this patent does not identify or locate a cause of a heart rhythm disorder. For instance, multiple activation paths in AF mean that the conduction path and thus conduction velocity is not known between the points used for triangulation. In addition, in the case of a rotor, activation sequences revolving around, or emanating symmetrically from, a core region may actually produce a net velocity of zero.
For these reasons, experts have stated that “no direct evidence of electrical rotors has been obtained in the human atria” in AF (Vaquero, Calvo et al. 2008). Thus, while it would be desirable to identify (and then locate) localized causes for human AF, this has not been possible.
For human AF, particularly persistent AF, the absence of identified and located causes means that ablation therapy is empiric and often involves damage to approximately 30%-40% of the atrium that could theoretically be avoided if the cause(s) were identified and located for minimally invasive ablation and/or surgical therapy (Cox 2005).
Human VT or VF are significant causes of death that are poorly treated by medications (Myerburg and Castellanos 2006). Treatment currently involves placing an implantable cardioverter defibrillator (ICD) in patients at risk, yet there is increasing interest in using ablation therapy to prevent repeated ICD shocks from VT/VF (Reddy, Reynolds et al. 2007). Identifying and locating causes for VT may be difficult and ablation is performed at specialized centers. In VF, animal data suggest that causes of VF lie at fixed regions near His-Purkinje tissue (Tabereaux, Walcott et al. 2007), but again this is very poorly understood in humans. The only prior descriptions of identifying and locating causes for VF required surgical exposure (Nash, Mourad et al. 2006) or were performed in hearts removed from the body after heart transplant (Masse, Downar et al. 2007)). Thus, minimally invasive ablation for VF focuses on identifying its triggers in rare cases (Knecht, Sacher et al. 2009) but cannot yet be performed in a wider population.
Existing sensing tools are also suboptimal for identifying and locating cause(s) for complex disorders such as AF, including single or multi-sensor designs exist (such as U.S. Pat. No. 5,848,972 by Triedman et al.). However, such tools typically have a limited field of view that is inadequate to identify causes for AF, that may lie anywhere in either atria and vary (Waldo and Feld 2008). Alternatively, they may require so many amplifiers for wide-area sampling that they are impractical for human use. Wide area sampling is advantageous and, in animals, is achieved by exposing the heart surgically (Ryu, Shroff et al. 2005) or removing it from the body (Skanes, Mandapati et al. 1998; Warren, Guha et al. 2003). In humans, even surgical studies only examine partial regions at any one time (for instance (Sahadevan, Ryu et al. 2004)), and introduce problems by exposing the heart to air, anesthesia and other agents that may alter the rhythm disorder from the form that occurs clinically.
Thus, prior systems and methods have largely focused on mapping of the anatomy of the heart to identify whether a patient has a heart rhythm disorder, rather than determining the cause or source of the rhythm disorder, and defining its size and shape within the heart. There is an urgent need for methods and tools to directly identify and locate causes for heart rhythm disorders in individual patients to enable curative therapy. This is particularly critical for AF and other complex rhythm disorders for which, ideally, a system and method would detect, locate and define the size and shape of the localized cause(s) for ablation therapy that can be delivered by minimally invasive, surgical or other methods.